Common use of Medicare Clause in Contracts

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines thereto. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or the Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoguidelines. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third third-party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third third-party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third third-party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or the Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoguidelines. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid for by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third third-party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third third-party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third third-party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoguidelines. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts outstandingamounts for unpaid services not covered by other third third-party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third third-party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third third-party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoguidelines. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third third-party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third third-party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third third-party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCEPart

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services after they are no longer eligible for coverage under Part A. Medicare does not cover deluxe private rooms or luxury amenities. Medicare also does not cover private (single occupancy) rooms unless medically necessary. If a Medicare Resident and/or Designated Representative and/or Sponsor requests a private room, when Part A coverage endsnot medically necessary, or a deluxe private room, he or she understands that there will be a charge for such private room or deluxe private room, not covered by Medicare, and that the Facility will charge the Medicare Resident at the Facility’s applicable differential private rate for each day the Medicare Resident occupies the private room or deluxe private room. The Resident and/or Designated Representative and/or Sponsor will be informed of the applicable daily differential private rate at the time of the request. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or the Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoguidelines. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services after they are no longer eligible for coverage under Part A. Medicare does not cover deluxe private rooms or luxury amenities. Medicare also does not cover private (single occupancy) rooms unless medically necessary. If a Medicare Resident and/or Designated Representative requests a private room, when Part A coverage endsnot medically necessary, or a deluxe private room, he or she understands that there will be a charge for such private room or deluxe private room, not covered by Medicare, and that the Facility will charge the Medicare Resident at the Facility’s applicable differential private rate for each day the Medicare Resident occupies the private room or deluxe private room. The Resident and/or Designated Representative will be informed of the applicable daily differential private rate at the time of the request. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoguidelines. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or the Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Admission Agreement (7/2015) For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, the Designated Representative and/or the Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. MEDICARE PART A BENEFICIARIES Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE.

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, Designated Representative and/or Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. For further information on third party payor sources, please refer to Attachment “B”. Admission Agreement (7/2015) Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If you have Medicare, you will be billed only for the Resident meets the eligibility requirements for skilled nursing facility benefits under unpaid portion of the Medicare Part A Hospital Insurance Programallowed services. Your co-insurance will be billed as a courtesy. Professional Foot and Ankle Center is a participating Medicare provider. Federal law requires all patients be billed for the unpaid 20% of their Medicare-covered services and for their annual deductible. HMO Please note that the authorization is for requested services only and the expiration date is the last date on which the authorization can be used. After such date, the Facility authorization will bill Medicare directly for Part A services provided no longer be valid. All payments are subject to the Residentmember’s updated eligibility, covered benefits, medical policy and reimbursement schedules. Medicare Services rendered that exceed benefit limitations, even if authorized, will reimburse be the Facility a fixed per diem or daily fee member’s financial responsibility. The authorization does not confirm eligibility. Payment of services is based on the Residentmember’s classification within participation in the Medicare RUG IV guidelines or successor guidelines theretoHealth Plan program at the time of the visit. Additionally, HealthCare Partners processes and pays claims according to CMS guidelines. This includes the use of the National Correct Coding Initiative edits which promotes correct coding methodologies and controls the improper coding that leads to inappropriate compensation. If the Resident continues additional care or visits are required, they must be authorized prior to be eligible, Medicare may provide coverage of up to 100 days of carecare being rendered. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby ALL PATIENTS I agree to pay allow Professional Foot and Ankle Center to the Facility accept third-party payments from my insurance company; however, I agree to take financial responsibility for co-payments, deductibles, and any outstanding amounts for unpaid services not covered by my insurance company. Please remember that insurance is considered a method of paying for health care costs. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. By your signature below, you hereby agree that it is your responsibility to pay any deductible, co-insurance, co-payment or any other third party payers, subject to applicable federal and state laws and regulationsallowed amount not paid for by insurance. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility Our office is not responsible for furnishing directlyinaccurate or incomplete information supplied by you or your insurance company, and you accept full responsibility for payment should you or the insurer supply us with wrong, incomplete, or arranging forfalse information. In order to control our cost of billing, office co- payments, co-insurance and deductibles are due on the day you are seen. MISSED APPOINTMENTS I understand that appointments are pre-arranged and it is my responsibility to keep the appointment or cancel with a minimum of 24 hour notice. I understand that I may be billed $50.00 for any missed appointments. I have read and understand the above information and accept full responsibility if my insurance does not pay for services for its residents covered by Medicare Part A and MCOsrendered, as well as any collection and/or legal costs incurred due to non-payment. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility Signature of patient or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third Responsible party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCEDate

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, Designated Representative and/or Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to Admission Agreement (7/2015) the Resident. For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY

Medicare. If the Resident meets the eligibility requirements for skilled nursing facility Skilled Nursing Facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill xxxx Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines theretoRUGS III guidelines. If the Resident continues to be eligiblemeets the eligibility criteria, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are may be fully paid by Medicare for, and the next 80 days (days 21 through 100) of the covered services are may be paid in part for by Medicare and subject to a daily coinsurance co-insurance amount for which the Resident is responsible. Please note, an individual who is a Medicare beneficiary under Part A Resident with Medicare and Part B and/or Part D coverageprograms, and who subsequently exhausts his/her their coverage under Part A coverage or is no longer needs in need of a skilled covered level of skilled care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or and Part D services when after they are no longer eligible for coverage under Part A coverage ends. A. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident Resident, Designated Representative and/or Sponsor would be responsible for the cost of his/her such stay, in accordance with applicable Federal and State laws and regulations, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facilitycoverage, the Resident, Resident Representative, Designated Representative and/or Sponsor hereby agree to pay remit to the Facility any outstanding amounts for unpaid services not covered by other third party payers, payors subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Admission Agreement (7/2015) For further information on third party payor sources, please refer to Attachment “B”. Except for specifically excluded services, most nursing home services provided to Medicare Part A beneficiaries are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs)requirements. Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. A. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from of the Facility. MEDICARE PART A, MANAGED CARE, A BENEFICIARIES V. AUTHORIZATIONS AND THIRD-PARTY INSURANCEASSIGNMENTS TO THE FACILITY